Resistance to last-line antibiotics is projected to reach up to 82% within the next decade, while a new Northern Territory project aims to address AMR rates up to four times higher than the national average in remote communities.
AMR is increasing globally among children, while remote and rural Australian communities face some of the highest rates of resistance and significant barriers to appropriate antibiotic prescribing.
A recent study, published in JAMA Pediatrics, projected resistance to carbapenems – often considered last-line treatments for serious infections caused by multidrug-resistant Gram-negative bacteria – could reach 82% for Acinetobacter baumannii and 35% for Klebsiella species by 2035.
The research project, led by the Murdoch Children’s Research Institute (MCRI) in collaboration with the University of Sydney, the Clinton Health Access Initiative, and the Chinese University of Hong Kong, created a world-first monitoring platform that was used to analyse more than 106,000 infection samples from children aged up to 18 years across 82 countries.
The researchers found that antimicrobial resistance increased in every region between 2004 and 2022. Resistance was consistently higher and increased more rapidly in resource-limited settings, while the youngest children and those in intensive care were among the most affected.
Resistance was particularly concerning among Gram-negative bacteria responsible for severe infections such as sepsis and pneumonia. Resistance increased most rapidly to antibiotics classified by the World Health Organization as ‘Watch’ and ‘Reserve’ antibiotics – drugs prioritised for careful use to preserve their effectiveness when first-line treatments fail.
Among the 106,581 children included in the study, 47% were aged zero to two years, 35% were aged three to 12 years and 18% were aged 13 to 18 years. Most samples came from medical wards and intensive care units, with blood, sputum, and skin or wound samples among the most common sources.
Resistance to Access antibiotics, which are generally recommended as first- or second-line treatments, was highest overall, with a mean resistance of 36% across the study period. Mean resistance was 22% for Watch antibiotics and 13% for Reserve antibiotics.
However, resistance to Watch and Reserve antibiotics increased most rapidly in intensive care units. Watch antibiotic resistance increased from 15% to 33% during the study period, with particularly marked increases among children aged zero to two years and those with sepsis or respiratory infections.
The findings were driven largely by Gram-negative pathogens. Acinetobacter baumannii, which can cause hospital-acquired bloodstream infections and pneumonia, had the highest overall resistance, with resistance exceeding 55% across each WHO AWaRe antibiotic category.
Klebsiella species recorded the fastest increases in resistance, particularly to third- and fourth-generation cephalosporins and carbapenems in Southeast Asia, Eastern Europe, and the Western Pacific.
MCRI Associate Professor Penelope Bryant, a clinician-scientist fellow and paediatric infectious diseases physician, told media the findings demonstrated a widening gap between recommended antibiotic use and the effectiveness of antibiotics in real-world clinical settings.
“Rising resistance to first- and now second-line drugs is the clinical reality for children,” Professor Bryant said.
The research team said better surveillance, targeted antimicrobial stewardship, and improved access to effective antibiotics were urgently needed. Without targeted action, the increasing resistance identified among children could leave clinicians with progressively fewer effective treatments for severe infections. The challenge will be to preserve the effectiveness of existing antibiotics while developing systems that ensure patients receive the right treatment when they need it.
The study’s newly launched AMR in Kids platform allows clinicians, researchers, and policymakers to explore resistance patterns by country, pathogen, and antibiotic class. It also provides region- and pathogen-specific forecasts to 2035, helping identify emerging threats and inform treatment and public health planning.
Dr Yanhong Jessika Hu, a researcher at MCRI and the University of Sydney, said combining almost two decades of global data with forecasting could help identify where resistance was likely to emerge before it became an even greater clinical challenge.
“Antimicrobial resistance is one of the biggest threats to children’s health globally, but until now we haven’t had a clear picture of how it’s changing specifically in children,” Dr Hu said.
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Meanwhile, researchers from Flinders University have received almost $5 million from the Medical Research Future Fund to address AMR in remote areas of the Northern Territory, where limited access to healthcare and specialist support can make appropriate diagnosis and treatment more difficult.
The Tackling Antimicrobial Resistance in Remote Australia (TARRA) project will examine the factors driving AMR among First Nations people living in remote areas and develop a remote antimicrobial stewardship program designed for local primary healthcare settings.
According to Flinders University, shortcomings in diagnosis mean that 26% of antimicrobial prescriptions in remote primary healthcare clinics are considered unsuitable, while resistance rates for common bacteria can be up to four times higher than the national average.
These challenges are particularly significant for First Nations communities, who may experience limited access to healthcare and specialist support, while remote clinicians may face difficult decisions about whether patients with potentially serious infections are being adequately treated.
Dr Danny Tsai, a Flinders research pharmacist based at the Centre for Remote Health and Alice Springs Hospital, said concerns about undertreatment could contribute to antimicrobial overprescribing.
“It’s a complex problem,” they said. “Over-prescription of antimicrobials is driven by concerns of undertreatment in remote settings, limited access to specialist support, insufficient knowledge of AMR, geographic isolation from tertiary care centres and constrained healthcare resources.”
The new project will adapt existing hospital-based antimicrobial stewardship models for use in remote NT primary healthcare settings. The proposed program will include antimicrobial usage surveillance, a clinical decision support system tailored to local guidelines, virtual clinical support, targeted education, culturally appropriate health promotion, and monitoring for emerging AMR threats.
A clinical audit tool will also be customised for remote use, while education and health promotion resources will aim to improve health literacy around infections, treatment, and AMR among both healthcare providers and communities.
Dr Tsai said the program would be particularly important in remote settings where doctors may be in short supply and prescribing decisions may instead be made by remote area nurses or Aboriginal health practitioners.
They said remote-area prescribers needed more advice and that introducing hospital antimicrobial stewardship principles could provide significant benefits.
The TARRA project is intended to provide an operational framework that could be adapted for other remote primary healthcare settings with similar populations and healthcare challenges.
